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April
2007: VOLUME
1, NUMBER 1
Welcome...
Johns
Hopkins University School of Medicine, The Institute for Johns Hopkins
Nursing and the University of Tennessee College of Pharmacy are pleased
to welcome you to this premier issue of eMedicalDermatology
Review. Over the course of this series, we will be reporting
on issues critical to providing effective and safe care for patients
with medical dermatological conditions.
To receive CME/CNE/CPE credit:
after reading the newsletter, follow the instructions on the right side
of this page to complete your Post-Test.
If you find the information presented
in this series valuable, please recommend eMedicalDermatology
Review to your colleagues. The easiest way to do so is by viewing
this page.
In
This Issue...
Photodynamic Therapy for Acne
Acne is one of the most prevalent
skin diseases and a leading reason patients seek dermatologic care.
With few new treatments available for acne, we often must rely on our
standard topical and oral agents. Nodulocystic acne continues to plague
both patients and dermatologists alike, with little therapeutic options
other than oral isotretinoin, which has become cumbersome to use in
the past year because of the new regulatory issues.
However, over the past several
years, research has provided us with a new technology to offer our acne
patients. Photodynamic therapy, which has been used for a variety of
other skin disorders, has now been studied in acne. In this issue, we
review some of the research into photodynamic therapy for acne, focusing
on the mechanism of action and the use of different light sources. |
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Course
Directors
Bernard
A. Cohen, MD
Interim Chairman
of Dermatology,
Professor of Pediatrics
and Dermatology and Director of Pediatric Dermatology,
Johns Hopkins Children's
Center
Baltimore, MD
Susan
Matra Rabizadeh, MD, MBA
Department of Dermatology
Johns Hopkins Cosmetic
Center at Greenspring Station,
Baltimore, MD
Mark
Lebwohl, MD
Professor and Chairman
Department of Dermatology
The Mount Sinai School
of Medicine
New York, NY |
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GUEST
EDITOR OF THE MONTH |
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Commentary
& Reviews:
Susan
Matra Rabizadeh, MD, MBA
Department of Dermatology
Johns Hopkins Cosmetic
Center at Greenspring Station
Baltimore, MD |
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Guest
Faculty Disclosure
Susan
Matra Rabizadeh, MD, MBA, has disclosed no relationship
with commercial supporters.
Unlabeled / Unapproved Uses
The author has indicated the off-label use of Levulan in the treatment of acne. |
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The
Johns Hopkins University School of Medicine and The Institute for
Johns Hopkins Nursing take responsibility for the content, quality,
and the scientific integrity of this CE activity.
At the conclusion of this activity, participants should be
able to: |
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Describe
the mechanism by which photodynamic therapy (PDT) is theorized to
work in the treatment of acne |
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Identify
at least three different light sources that have been tested in
the treatment of acne using photodynamic therapy |
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Describe
the side effects associated with photodynamic therapy for acne |
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COMPLETE
THE POST TEST
Step
1.
Click on the appropriate link
below. This will take you to the post-test.
Step
2.
If you have participated in a
Johns Hopkins on-line course, login. Otherwise, please register.
Step
3.
Complete the post-test and course
evaluation.
Step
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Print out your certificate.
Pharmacy
credit is only available via PDF mail-in form:
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Acne
affects approximately 50 million Americans, and is responsible for
an estimated $3.1 billion spent annually on direct and indirect medical
costs[1]. The variety of topical and oral agents available
generally only control the disease; recurrences are frequent once the
medication is discontinued. While oral isotretinoin has been the most
successful treatment for moderate to severe acne, there is increasing
concern about its potential for side effects. Further, with the advent
of the iPLEDGE system, many dermatologists and patients are looking
for alternative treatments for acne.
The pathogenesis of acne is often
associated with several factors, including increased sebum production,
altered differentiation of the pilosebaceous duct, colonization of the
follicle by P. acnes, and inflammation[2]. Light based and
laser therapies have long been used to treat acne, primarily by targeting
P. acnes, the sebaceous gland, or both.
Topical photodynamic therapy
(PDT) uses the application of aminolevulinic acid (ALA), which is preferentially
taken up by the pilosebaceous units and metabolized through the heme
synthesis pathway to produce protoporphyrin IX. When protoporphyrin
is photoactivated, the singlet oxygen species and free radicals produced
are cytotoxic. This results in death of P. acnes and damage to the pilosebaceous
unit itself, as demonstrated in the study by Hongcharu et al (reviewed
herein). This information has led to numerous other studies that have
tried to delineate which light source is optimal for treating acne with
photodynamic therapy.
Initially, visible light was
studied, as ALA is activated in the visible spectrum. Small pilot studies
with PDT using blue light did find modest improvement in inflammatory
acne[3,4]; however blue light may be limited by the depth
of penetration. Red light-PDT appears to be effective for inflammatory
acne, as demonstrated in the Hongharu, Pollock, and Horfelt reports.
However, in all of these studies, there were severe adverse effects,
in particular pain, erythema, and hyperpigmentation. This may have been
due to the long incubation times used for the ALA, the light source,
or a combination of both.
Interestingly, the results from
studies using intense pulsed light (IPL) with photodynamic therapy (which
has one of the widest wavelength spectrums) have been more varied, as
demonstrated by both the Yeung and Santos studies. This may be attributable
to the variability in both settings and IPL units used among the different
studies. So far, the most impressive results stem from the study by
Alexiades-Armenakas, which analyzed the use of a long pulsed dye laser
with photodynamic therapy for acne. Other reports have also found benefit
with pulsed dye laser alone[5]. Photodynamic therapy using
the pulsed dye laser appears to be more effective than other light or
laser sources; it is speculated that part of this efficacy may be the
result of treating the erythema associated with inflammatory acne.
Photodynamic therapy is an exciting
new technology that is being used for a variety of dermatologic disorders,
and the initial studies for acne (reviewed herein) are quite promising.
The stage has been set for larger, randomized controlled trials that
will allow us to ultimately identify the best light source, settings,
incubation time, and protocol for treating our acne patients.
References
| 1. |
Bickers
DR, Lim HW, Margolis D, Weinstock MA, Goodman C, Faulkner E, Gould
C, Gemmen E. The
burden of skin diseases: 2004 a joint project of the American Academy
of Dermatology Association and the Society for Investigative Dermatology.
Journal of American Academy of Dermatology. 2006 Sep; 55(3) 490-500. |
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| 2. |
Nestor
MS. The
use of photodynamic therapy for treatment of acne vulgaris.
Dermatology clinics. 2007 Jan; 25(1): 47-57. |
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| 3. |
Goldman
MP, Boyce SM. A
single-center study of aminolevulinic acid and 417 nm photodynamic
therapy in the treatment of moderate to severe acne vulgaris.
Journal of Drugs in Dermatology. 2003 Aug; 2(4):393-6. |
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| 4. |
Taub
AF. Photodynamic
therapy for the treatment of acne: a pilot study. Journal of
drugs in dermatology. 2004 Nov-Dec; 3(6 suppl): S10-4 |
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| 5. |
Seaton
ED, Charakida A, Mouser PE, Grace I, Clement RM, Chu AC. Pulsed
dye laser treatment for inflammatory acne vulgaris: randomized controlled
trial. Lancet. 2003; 362(9393):1342. |
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PHOTODYNAMIC
THERAPY (PDT) FOR ACNE: EFFICACY |
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Wichai
Hongcharu, Charles R. Taylor, Yuchaio Chang, David Aghassi, Kittisak
Suthamjariya, R. Rox Anderson. Topical ALA-photodynamic
therapy for the treatment of acne vulgaris. Journal
of Investigative Dermatology, 115: 183-192, 2000.
(For non-journal subscribers, an additional fee may apply
for full text articles.) |
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One
of the first open label prospective studies using photodynamic therapy
for acne was performed in 2000 by Hongcharu et al. 22 subjects with
acne on the back were treated in four sites with aminolevulinic acid
(ALA) plus red light, aminolevulinic acid alone, red light alone,
or untreated control. 20% topical ALA was applied for 3 hours under
occlusion and 150J/cm2 of broad band light (550-700nm)
was given. Subjects were randomized to single-treatment and multiple-treatment
groups. In the multiple-treatment group, subjects were treated once
a week for 4 consecutive weeks. Clinical evaluation using an inflammatory
acne score was globally assessed by three blinded dermatologists.
Fluorescence of hair follicles populated with P. acnes was measured,
and sebum-absorbent tape was used to evaluate human sebum excretion.
These parameters were measured at baseline, and at 2, 3, 10, and
20 weeks after treatment. Punch biopsies were taken immediately after
PDT, a few weeks after, and at 20 weeks after, from both untreated
control and ALA-PDT treated areas. Sebaceous gland area and the cytoplasm/nuclear
area ratio in sebocytes were calculated and compared between the
control and PDT areas at each follow-up. Protoporphyrin IX production
and localization was also analyzed from biopsies taken 3 hours after
ALA incubation.
The researchers found
statistically significant improvements in acne with ALA-red light
for up to 20 weeks in the multiple-treatment group, and for up to
10 weeks in the single-treatment group — compared to ALA alone,
light alone, or untreated sites. The global clinical improvement
score of the PDT sites also showed significant improvement compared
to controls. Only the PDT treated sites showed significant loss of
fluorescence related to P. acnes in both the single and multiple
treatment groups, a finding that was reported out to 20 weeks. Also,
only those groups treated with PDT showed a significant decrease
in sebum output at all follow-up visits. Histologically, there was
a decrease in sebaceous gland size with frank sebaceous gland destruction
by a mixed neutrophil predominant infiltrate, as well as a decrease
in the cytoplasm/nuclear area ratio. These results were more pronounced
at 20 weeks in the multi-treatment group than in the single treatment
group. An acute eruption of inflammatory acneiform lesions was observed
in the ALA-PDT sites in all patients starting 3-4 days post treatment.
In the multiple-treatment group, less acne was produced after each
treatment, such that almost no new lesions were observed after treatment
four. Subjects reported pain, burning and itch during treatment,
and erythema, edema, hyperpigmentation, and exfoliation were seen,
although in most patients these resolved within several weeks.
In normal epidermis,
hair follicles and sebaceous glands accumulate protoporphyrin IX
after systemic ALA administration[1]. Hongcharu’s study
shows that ALA-induced protoporphyrin IX fluorescence is greater
in acne lesions than in surrounding tissue. This sentinel study suggests
therefore that ALA-PDT may have several modes of action, including:
direct damage to sebaceous glands that may inhibit sebum production;
killing of P. acnes; and possibly reducing follicular obstruction
by changing keratinocyte shedding and hyperkeratosis. Note, however,
that the study is limited by its small size and aggressive approach
to applying and incubating ALA. Further, the long incubation may
have led to fairly significant pain and side effects. Those concerns
notwithstanding, this pilot study was one of the first to show clinical
improvement in acne using photodynamic therapy; in addition, the
histological and fluorescence evaluations suggest mechanistically
how photodynamic therapy may work in acne.
References
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PDT
WITH RED LIGHT FOR ACNE: CLINICAL EFFICACY AND MECHANISMS |
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Pollock
B, Turner D, Stringer MR, Bojar RA, Goulden V, Stables GI Cunliffe
WJ. Topical aminolevulinic acid-photodynamic therapy for
the treatment of acne vulgaris: a study of clinical efficacy and
mechanism of action. British Journal of Dermatology. Sep
2004, 151(3): 616.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Horfelt
C, Funk J, Frohm-Nilsson M, Wiegleb Edstrom D, Wennberg AM. Topical
methyl aminolevulinate photyodynamic therapy for treatment of facial
acne vulgaris: results of a randomized, controlled trial. British
Journal of Dermtology. Sep 2006; 155(3) 608-613.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Pollock’s
2004 follow-up to Hongharu’s 2000 study looked at 10 patients with acne
and evaluated four equally affected sites on their backs with ALA-PDT,
light alone, ALA alone, or an untreated control site. Lesion counts
were performed, sebum excretion measured, and P. acnes swabs performed
at baseline and following each treatment. 20% ALA cream was applied
under occlusion to the treatment sites for 3 hours. Diode laser was
used (635nm, 25 mW/cm2, 15 J/cm2) as a red light
source. Porphyrin fluorescence spectra were recorded at the skin surface
before and after each treatment. Patients were treated weekly for 3
weeks.
Two years later, Horfelt et al
studied 30 patients with moderate to severe acne in a blinded, prospective,
randomized, placebo-controlled multicenter trail. A split-face design
randomized subjects to either methyl aminolevulinic acid (MAL) cream
or placebo, occluded and incubated for 3 hours. A non-coherent red light
(average wavelength of 635 nm, light dose 37 J/cm2) was used to illuminate
both sides. All subjects received a second treatment 2 weeks later.
They were evaluated at baseline and again at 4 and at 10 weeks after
the last PDT treatment.
Results from Pollock’s study showed a statistically significant reduction
in inflammatory acne lesion counts from baseline after the second treatment
only at the ALA-PDT site. Although the number of P. acnes was reduced
in the ALA-PDT site, and there was a trend toward decreased sebum production
in the ALA-PDT and light alone sites, neither finding reached statistical
significance. Main adverse events were discomfort during the procedure,
and mild urticarial or perifollicular eruption that resolved within
1-2 hours after the procedure. Post inflammatory hyperpigmention was
seen in all subjects.
The Horfelt study found that
the MAL-PDT therapy was significantly more effective than placebo in
treating inflammatory lesions, with a median reduction of 63% vs 28%
and 54% vs 20% at weeks 6 and 12 respectively. No statistical difference
was noted in non-inflammatory lesions. Seventy percent of subjects reported
adverse events, most frequently pain, erythema, and edema that lasted
7-10 days. Three subjects dropped out because of erythema and pain.
Although the number of patients
enrolled was small, both studies found improvement with the 2 different
(20% ALA cream and MAL) topical formulations used for photodynamic therapy.
It is interesting to note that Pollock’s group was able to achieve clinical
results without significantly affecting sebum production or density
of P. acnes as previously suggested by Hongharu - part of that difference
could lie in the light source (one wavelength vs broad band light),
a different formulation of ALA (20% ALA cream vs 20% solution), and/or
the length and number of treatments. Regardless of the true mechanism,
it appears that ALA-PDT does have a clinical impact in improving acne.
Although both red and blue light in the visible spectrum have been studied
with PDT, these reports indicate that red light may be more effective
than blue light, partially owing to its greater depth of penetration. |
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PDT
FOR ACNE: INTENSE PULSED LIGHT (IPL) |
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Yeung
CK, Shek SY, Bjerring P, Yu CS, Kono T, Chan H. A comparative
study of intene pulsed light alone and its combination with photodynamic
therapy for the treatment of facial acne in asian skin. Lasers
in surgery and medicine 39(1): 6, 2007.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Santos
MA, Belo VG, Santos G. Effectiveness of photodynamic therapy
with topical 5-aminolevulinic acid and intense pulsed light verses
intense pulsed light alone in the treatment of acne vulgaris: comparative
study. Dermatologic Surgery 2005 August; 31(8 part 1):
910-5.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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Yeung
et al studied 30 Chinese subjects with phototypes IV or V skin and moderate
acne in a randomized, prospective, single blind, split-face trial. Subjects
were randomized to half-facial treatments with methyl aminolevulinate
(MAL) plus intense pulsed light (IPL), IPL alone, or control. One group
received half-face with IPL and other side control; the other group
received half-face PDT-IPL vs IPL alone. Photographs were taken before
each treatment and at one month and at three months after the last treatment.
Subjects received a total of four treatments at 3 week intervals. P.
acnes fluorescence was also measured. The IPL wavelengths used were
532 nm and 577 nm, fluences of 7-9 J/cm2 and spot size of
10x48 mm. All patients used adapalene 0.1% gel throughout the study.
The Santos study also looked
at 15 subjects with acne using IPL with PDT. After a 3 week washout
period, 20% ALA was applied to half the face; after 3 hours the entire
face was then exposed to intense pulsed light with settings of 560 nm,
fluence of 26 J/cm2. The procedure was done twice at 2 week
intervals. Clinical evaluation was done on the second, fourth, and eighth
weeks.
The results of the Yeung study
were surprising, showing a 53% reduction in inflammatory lesion counts
in the PDT-IPL group, 22% in the IPL alone group, and 72% in the control
group after 4 weeks of treatment. Further, after 12 weeks post treatment,
reduction in lesion counts were 65%, 23%, and 88% in the PDT-IPL, IPL
alone, and control group respectively. Interestingly, reduction in non-inflammatory
lesion counts was statistically significant for the ALA-PDT group compared
with IPL alone or control groups after both 4 and 12 weeks, which is
not a finding consistently seen in other studies. Although there was
a trend toward greater reduction in fluorescence of P. acnes in the
PDT group, the results were not statistically significant. Adverse effects
were stinging, burning, erythema and edema, actue acneiform eruption,
and some subjects in the PDT group had hyperpigmentation and crusting.
The Santos study found that most
of the patients had visible improvement of facial acne on the ALA treated
side of the face that persisted until 8 weeks post treatment, while
at 8 weeks from the first treatment the IPL side was not significantly
different. Most patients developed an acute eruption of acneiform lesions
on the ALA-treated side 2 weeks after the first treatment, which improved
by the fourth week.
Why did these two studies using
IPL-PDT for acne show such different results, with Yeung’s group reporting
no improvement over baseline in the treatment group (in fact the control
group improved more overall), versus the majority of Santos’ patients
responding clinically to IPL-PDT? Possible reasons for this difference
in outcome include the small sample size of both studies, the use of
different IPL machines with different settings, possibly darker skin
subjects in Yeung’s study (which limits the IPL settings), and the use
of methyl aminolevulinic acid versus 20% 5-aminolevunilic acid. Further,
an additional randomized split-face study (by Wiegell[1])comparing
the treatment effect and tolerability of 5-aminolevulinic acid and methyl
aminolevulinic acid for acne using red light found no difference in
response rate, tolerability, or adverse events.
As one of the biggest issues
with using an IPL as a light source is the variability among the different
machines and adjustable variables within the same machine; studies therefore
are often difficult to compare. Ultimately, however, there appears to
be ample evidence that IPL-PDT can be an effective adjuvant treatment
for acne in some patients.
References
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PDT
FOR ACNE: PULSED DYE LASER |
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Alexiades-Armenakas,
M. Long-pulsed dye laser-mediated photodynamic therapy combined
with topical therapy for mild to severe comedonal, inflammatory
or cystic acne. Journal of drugs in dermatology. Jan 2006;
5(1): 45-55.
(For non-journal subscribers, an additional fee may apply for
full text articles.) |
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In
this 2006 report, pulsed dye laser was used to evaluate efficacy in
acne with concomitant use of PDT. This prospective, controlled, proof-of-principle
study evaluated 19 patients with mild to severe acne. Skin types I-VI
were included. 20% ALA was incubated for 45 minutes on the face, then
treated with pulsed dye laser 595 nm, 7.0-7.5 J/cm2, 10 ms,
10 mm spot size. Patients received 1-6 monthly treatments. 14 patients
were treated and 4 patients were used as controls. Patients were clinically
evaluated at baseline and at each monthly follow-up.
In the pulsed dye mediated PDT
group, Alexiades-Armenekas found complete clearance in 100% of patients,
which was maintained for up to 13 months. Mean number of treatments
to achieve clearance was 2.9 with mean follow-up of 6.4 months. Mean
percent lesional clearance was 77% per treatment. All patients were
maintained on their topical regimen, and additionally four patients
received chemical peels every 2-4 months during follow-up. In the control
patients who received just pulsed dye laser, the mean clearance rate
per treatment was 32% without complete clearance after 3-4 treatments.
In controls receiving conventional treatments (oral antibiotics and/or
oral contraceptives, chemical peels, and topical medications without
PDT), mean lesional clearance was 20% per treatment and clearance was
not achieved after 6-10 months. Side effects reported in the pulsed-dye-PDT
group include mild pain, erythema, and desquamation over a 1 week interval.
The findings of this small study
hold significant promise for pulsed-dye laser PDT as a safe and effective
therapy for acne of all severities. In particular, the procedure appears
be a good alternative to isotretinoin in severe acne cases. However,
the study’s limitations include small sample size, inadequate number
of controls, and a significant number of variables and potential confounders,
such as variability in topical acne regimens and number of treatments.
In addition, only a visual clinical scale was used to evaluate clearance
and efficacy. More definitive data would have been provided had the
authors also reported on histology of the sebaceous glands, sebum production,
and fluorescence of P. acnes. |
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Statement — back
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This
activity has been planned and implemented in accordance with the
Essential Areas and Policies of the Accreditation Council for Continuing
Medical Education through the joint sponsorship of The Johns Hopkins
University School of Medicine, The Institute for Johns Hopkins Nursing,
and the University of Tennessee College of Pharmacy. The Johns Hopkins
University School of Medicine is accredited by the ACCME to provide
continuing medical education for physicians.
The Institute for
Johns Hopkins Nursing is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s Commission
on Accreditation |
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Physicians
The Johns Hopkins
University School of Medicine designates this educational activity
for a maximum of 1.0 AMA PRA Category 1 Credit(s)TM.
Physicians should only claim credit commensurate with the extent
of their participation in the activity.
Nurses
This 1 contact hour
Educational Activity (Provider Directed/Learner Paced) is provided
by The Institute for Johns Hopkins Nursing. Each Newsletter carries
a maximum of 1 contact hour or a total of 6 contact hours for the
twelve newsletters in this program.
Pharmacists
 This
program is approved for one hour credit (0.1 CEUs) for the newsletter
and 0.5 hour credit (0.05 CEUs) for the podcast and is co-sponsored
by the University of Tennessee College of Pharmacy who is accredited
by the Accreditation Council for Pharmacy Education as a provider
of continuing pharmacy education. A statement of CE credit will be
mailed within 4 weeks of successful completion and evaluation of
the program. ACPE Program #064-999-07-250-H01.
Grievance Policy: A participant, sponsor, faculty
member or other individual wanting to file a grievance with respect
to any aspect of a program sponsored or co-sponsored by the UTCOP
may contact the Associate Dean for Continuing Education in writing.
The grievance will be reviewed and a response will be returned within
45 days of receiving the written statement. If not satisfied, an
appeal to the Dean of the College of Pharmacy can be made for a second
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Johns Hopkins University School of Medicine and The Institute for
Johns Hopkins Nursing takes responsibility for the content, quality,
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activity has been developed for the Dermatologist, PharmD, Nursing,
Dermasurgeon, Dermatopathologist, Pediatric Dermatologist, Immunodermatologist,
Wound Care Specialist. |
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The
Johns Hopkins University School of Medicine and The Institute
for Johns Hopkins Nursing take responsibility for the content,
quality, and the scientific integrity of this CE activity.
At the
conclusion of this activity, participants should be able to: |
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Describe
the mechanism by which photodynamic therapy (PDT) is theorized
to work in the treatment of acne |
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Identify
at least three different light sources that have been tested
in the treatment of acne using photodynamic therapy |
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Describe
the side effects associated with photodynamic therapy for acne |
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| Internet
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The
Offices of Continuing Education (CE) at The Johns Hopkins University
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It
is the policy of The Johns Hopkins University School of Medicine,
The Institute for Johns Hopkins Nursing, and The University of Tennessee
College of Pharmacy that the faculty and provider disclose real
or apparent conflicts of interest relating to the topics of this
educational activity, and also disclose discussions of unlabeled/unapproved
uses of drugs or devices during their presentation(s). Johns Hopkins
School of Medicine OCME, The Institute for Johns Hopkins Nursing
and The University of Tennessee College of Pharmacy has established
policies in place that will identify and resolve all conflicts of
interest prior to this educational activity. Detailed disclosures
will be made in the course handout materials.
The presenting faculty
reported the following:
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Bernard
A. Cohen, MD has indicated a past and current financial relationship
with Novartis, Pharmaceuticals, Astellas Pharma Inc., Medicis
and Connetics. He served on the Speaker's Bureau for Novartis,
Pharmaceuticals, Astellas Pharma Inc., and Medicis. He has also
received grants for studies from Novartis, Pharmaceuticals and
Astellas Pharma Inc. and received support for a fellowship program
from Connetics. |
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Susan
Matra Rabizadeh MD, MBA has disclosed no relationship with commercial
supporters. |
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Mark
Lebwohl, MD has disclosed that he has received grants for clinical
research and educational activities from, has served as an advisor
or consultant to, and has served as an investigator for Novartis
and Astellas. Dr. Lebwohl has also disclosed that he serves as
a speaker for Astellas. |
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| Disclaimer
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| The
opinions and recommendations expressed by faculty and other experts
whose input is included in this program are their own. This enduring
material is produced for educational purposes only. Use of Johns
Hopkins University School of Medicine Medicine and The University
of Tennessee College of Pharmacy name implies review of educational
format design and approach. Please review the complete prescribing
information of specific drugs or combination of drugs, including
indications, contraindications, warnings and adverse effects before
administering pharmacologic therapy to patients. |
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COMPLETE
THE POST TEST
Step
1.
Click on the appropriate link below. This
will take you to the post-test.
Step
2.
If you have participated in a Johns Hopkins
on-line course, login. Otherwise, please register.
Step
3.
Complete the post-test and course evaluation.
Step
4.
Print out your certificate.
Pharmacy
credit is only available via PDF mail-in form:
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© 2007
JHUSOM, IJHN, UTCP, and eMedicalDermatology Review
Created by DKBmed. |
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